Healthcare Provider Details

I. General information

NPI: 1730199860
Provider Name (Legal Business Name): JOHN W LYZANCHUK DO
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/09/2006
Last Update Date: 07/23/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

611 N 39TH AVE
YAKIMA WA
98902-6348
US

IV. Provider business mailing address

611 N 39TH AVE
YAKIMA WA
98902
US

V. Phone/Fax

Practice location:
  • Phone: 509-249-1288
  • Fax: 509-249-6249
Mailing address:
  • Phone: 509-249-1288
  • Fax: 509-249-6249

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberOP00000730
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: